Cardiac Surgery
RCT: Transcatheter Repair Noninferior to Mitral-Valve Surgery for Secondary Mitral Regurgitation
12 Sep, 2024 | 12:13h | UTCStudy Design and Population: This noninferiority trial, conducted in Germany, enrolled 210 patients with heart failure and secondary mitral regurgitation who remained symptomatic despite medical therapy. Patients were randomized to undergo either transcatheter edge-to-edge repair or mitral-valve surgery, with outcomes assessed over a one-year period.
Main Findings: Transcatheter repair was found to be noninferior to mitral-valve surgery regarding the primary efficacy outcome—a composite of death, heart failure hospitalization, mitral-valve reintervention, assist device implantation, or stroke at one year (16.7% in the transcatheter group vs. 22.5% in the surgery group; mean difference, -6%; 95% CI, -17 to 6; P<0.001 for noninferiority). The transcatheter group experienced fewer major adverse events within 30 days (14.9% vs. 54.8%; mean difference, -40%; 95% CI, -51 to -27; P<0.001).
Implications for Practice: Transcatheter edge-to-edge repair offers a similar efficacy to mitral-valve surgery at one year with a lower rate of short-term adverse events, suggesting it may be a suitable alternative, particularly for patients with higher surgical risk.
2024 ESC Guidelines for the Management of Chronic Coronary Syndromes
1 Sep, 2024 | 18:49h | UTCIntroduction: The 2024 guidelines were developed by the European Society of Cardiology (ESC) with the endorsement of the European Association for Cardio-Thoracic Surgery (EACTS). These guidelines provide updated recommendations for the management of chronic coronary syndromes (CCS), focusing on the diagnosis, treatment, and long-term care of patients with stable coronary artery disease (CAD).
Key Points:
1 – History and Risk Assessment:
– Detailed assessment of cardiovascular risk factors, medical history, and symptom characteristics is essential in patients with suspected CCS.
– Symptoms like chest pain triggered by emotional stress, dyspnea on exertion, or fatigue should be considered potential angina equivalents.
2 – Diagnostic Testing:
– Coronary Computed Tomography Angiography (CCTA): Recommended as a first-line diagnostic tool for patients with low to moderate pre-test likelihood of obstructive CAD.
– Stress Imaging: Stress echocardiography, SPECT, PET, or cardiac MRI is recommended for those with moderate to high pre-test likelihood to diagnose myocardial ischemia and estimate the risk of major adverse cardiovascular events (MACE).
3 – Revascularization Indications:
– Symptom Relief: Revascularization is recommended for patients with obstructive CAD who have significant symptoms despite optimal medical therapy.
– Prognostic Benefit: Indicated in patients with left main coronary artery disease, severe three-vessel disease, or two-vessel disease including proximal left anterior descending artery stenosis, particularly if associated with reduced left ventricular function.
– High-Risk Anatomical Features: Revascularization is advised when significant stenosis is present in patients with high-risk anatomical features identified by imaging, especially if non-invasive testing shows a large area of ischemia.
4 – Lifestyle and Risk Management:
– A comprehensive approach to cardiovascular risk reduction, including lifestyle changes (e.g., smoking cessation, diet, and physical activity) and guideline-directed medical therapy, is strongly recommended.
– Home-based cardiac rehabilitation and digital health interventions are suggested to improve long-term adherence to healthy behaviors.
5 – Antianginal and Antithrombotic Therapy:
– Tailoring antianginal therapy based on individual patient characteristics, comorbidities, and local drug availability is recommended.
– Long-term antithrombotic therapy with aspirin or clopidogrel is recommended for patients with prior myocardial infarction or revascularization.
Conclusion: The 2024 ESC guidelines emphasize a patient-centered approach, integrating advanced diagnostic tools and personalized therapeutic strategies to optimize outcomes for patients with chronic coronary syndromes. The guidelines highlight the importance of detailed risk assessment, appropriate use of diagnostic imaging, clear criteria for revascularization, and a strong focus on lifestyle interventions alongside pharmacological management.
RCT: Hypothermic Oxygenated Perfusion Trends Toward Lower Primary Graft Dysfunction in Heart Transplantation – The Lancet
17 Aug, 2024 | 19:38h | UTCStudy Design and Population: This randomized, controlled, open-label, multicenter clinical trial evaluated the safety and efficacy of hypothermic oxygenated machine perfusion (HOPE) compared to static cold storage (SCS) in preserving donor hearts for transplantation. Conducted across 15 transplant centers in eight European countries, the study enrolled 229 adult heart transplant candidates between November 2020 and May 2023. The trial included 204 patients who received a transplant and met the study’s inclusion and exclusion criteria.
Main Findings: The primary composite endpoint, including cardiac-related death, graft dysfunction, and rejection within 30 days post-transplant, occurred in 19% of patients in the HOPE group compared to 30% in the SCS group, reflecting a 44% risk reduction (HR 0.56, 95% CI 0.32–0.99, p=0.059). Notably, primary graft dysfunction was significantly lower in the HOPE group (11% vs. 28%, RR 0.39, 95% CI 0.20–0.73). The incidence of major adverse cardiac transplant events was also reduced with HOPE (18% vs. 32%, RR 0.56, 95% CI 0.34–0.92).
Implications for Practice: HOPE showed a potential clinical benefit by reducing the incidence of primary graft dysfunction and major adverse cardiac events after heart transplantation. Although the primary endpoint was not statistically significant, the observed risk reductions suggest that HOPE could improve outcomes in heart transplantation. Further research is needed to confirm these findings and optimize donor heart preservation strategies.
RCT: Intravenous Amino Acids Reduce AKI Incidence in Cardiac Surgery Patients – N Engl J Med
3 Aug, 2024 | 19:12h | UTCStudy Design and Population: In this multinational, double-blind, randomized clinical trial, 3511 adult patients scheduled for cardiac surgery with cardiopulmonary bypass were recruited from 22 centers across three countries. Patients were randomly assigned to receive an intravenous infusion of either a balanced mixture of amino acids (2 g/kg/day) or a placebo (Ringer’s solution) for up to three days.
Main Findings: The primary outcome, occurrence of acute kidney injury (AKI), was significantly lower in the amino acid group (26.9%) compared to the placebo group (31.7%) with a relative risk of 0.85 (95% CI, 0.77 to 0.94; P=0.002). The incidence of severe AKI (stage 3) was also reduced in the amino acid group (1.6% vs. 3.0%; relative risk, 0.56; 95% CI, 0.35 to 0.87). There were no substantial differences between the groups regarding secondary outcomes such as the use and duration of kidney-replacement therapy or all-cause 30-day mortality.
Implications for Practice: The infusion of amino acids in adult patients undergoing cardiac surgery appears to reduce the incidence of AKI, indicating a potential protective renal effect. However, this intervention did not significantly impact other secondary outcomes, including mortality and the use of kidney-replacement therapy. These findings suggest that amino acids could be considered as a strategy to mitigate AKI risk in this patient population, although further research is needed to explore long-term benefits and other clinical outcomes.
PCI vs. CABG in left main coronary disease patients with and without diabetes—a pooled analysis of 4 trials
22 Mar, 2024 | 11:41h | UTCStudy Design and Population: This research pooled individual patient data from four randomized clinical trials (SYNTAX, PRECOMBAT, NOBLE, and EXCEL), comparing percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in 4393 patients with left main coronary artery disease. The trials included both patients with and without diabetes, allowing for a comparative analysis of outcomes based on the revascularization method and the presence of diabetes.
Main Findings: Patients with diabetes exhibited higher rates of 5-year mortality, spontaneous myocardial infarction (MI), and repeat revascularization compared to those without diabetes. However, mortality rates following PCI vs. CABG were similar in diabetic (15.3% vs. 14.1%, respectively) and non-diabetic patients (9.7% vs. 8.9%, respectively). PCI was associated with a lower risk of stroke within the first year post-operation across all patients. Notably, diabetic patients underwent higher rates of spontaneous MI and repeat revascularization after PCI compared to CABG, with a more significant absolute excess risk observed beyond the first year compared to non-diabetic patients.
Implications for Practice: For patients with left main disease deemed suitable for either PCI or CABG, diabetes status significantly influences long-term outcomes, including death and cardiovascular events. While PCI offers a lower early risk of stroke, it is associated with increased risks of spontaneous MI and repeat revascularization, particularly in diabetic patients. These findings underscore the importance of considering patient-specific factors, such as diabetes status, in choosing between PCI and CABG for left main coronary artery disease revascularization.
Reference
Prakriti Gaba et al. (2024). Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Left Main Disease With or Without Diabetes: Findings From a Pooled Analysis of 4 Randomized Clinical Trials. Circulation, 0. DOI: 10.1161/CIRCULATIONAHA.123.065571. Access the study here: Link
Case Report | Post-myocardial infarction free-wall rupture: rapid diagnosis and management
2 Aug, 2023 | 13:52h | UTCPost-Myocardial Infarction Free-Wall Rupture: Rapid Diagnosis and Management – JACC: Case Reports
Commentary on Twitter
Learn how to evaluate, diagnose and manage #cvMI wall rupture to improve survival in #JACCCaseReports' latest issue: https://t.co/aGPJ1rZ8eu#CardioTwitter #cvSurg #CathLab pic.twitter.com/bPTtJownNf
— JACC Journals (@JACCJournals) July 31, 2023
Study | Left ventricular dysfunction in brain-dead heart donors – incidence, reversibility, and implications
31 Jul, 2023 | 14:09h | UTCLeft Ventricular Dysfunction Associated With Brain Death: Results From the Donor Heart Study – Circulation (free for a limited period)
Pooled Analysis | Post-CABG graft failure found in 33.7% of patients, strongly linked to cardiac events
20 Jul, 2023 | 11:03h | UTCGraft Failure After Coronary Artery Bypass Grafting and Its Association With Patient Characteristics and Clinical Events: A Pooled Individual Patient Data Analysis of Clinical Trials With Imaging Follow-Up – Circulation (free for a limited period)
Commentary on Twitter
#OriginalResearch: In this analysis pooling individual level data from randomized trails, graft failure occured in 34% of patients undergoing CABG and was associated w/ increased risk of adverse clinical events #AHAJournals @WCM_CTSurgery https://t.co/Vg7t56pg0x pic.twitter.com/gmseiefME0
— Circulation (@CircAHA) July 18, 2023
AHA Statement | Indications, evaluation, and outcomes for dual heart-kidney and heart-liver transplantation
14 Jul, 2023 | 12:51h | UTC
Consensus Paper | Adult cardiac surgery-associated acute kidney injury
7 Jul, 2023 | 16:18h | UTC
AHA Scientific Statement | Considerations on the management of acute postoperative ischemia after cardiac surgery
29 Jun, 2023 | 14:07h | UTC
Editorial | How to become a good surgeon
22 Jun, 2023 | 15:12h | UTCHow to become a good surgeon – Advances in Ophthalmology Practice and Research
RCT | No superior recovery with minithoracotomy over sternotomy in mitral valve repair
20 Jun, 2023 | 12:51h | UTCMinithoracotomy vs Conventional Sternotomy for Mitral Valve Repair: A Randomized Clinical Trial – JAMA (free for a limited period)
See also: Visual Abstract
M-A | Similar death rates in left main disease patients treated with PCI or CABG, both in patients with and without ACS
15 Jun, 2023 | 14:59h | UTCPercutaneous Coronary Intervention vs Coronary Artery Bypass Graft Surgery for Left Main Disease in Patients With and Without Acute Coronary Syndromes: A Pooled Analysis of 4 Randomized Clinical Trials – JAMA Cardiology (link to abstract – $ for full-text)
Commentary: CABG and PCI Comparable in ACS Patients With Left Main CAD – TCTMD
RCT | Noninferior survival rates with hearts donated after circulatory death versus brain death
12 Jun, 2023 | 13:57h | UTCTransplantation Outcomes with Donor Hearts after Circulatory Death – New England Journal of Medicine (link to abstract – $ for full-text)
Video summary: Outcomes with Donor Hearts after Circulatory Death | NEJM
News Release: Multicenter Trial Finds Using Circulatory Death Donors is Safe and Effective for Heart Transplantation – Northwestern Medicine
Commentary: Transplantation Outcomes With Donor Hearts After Circulatory Death – American College of Cardiology
Commentary on Twitter
In a randomized trial, survival at 6 months after transplantation with hearts donated after circulatory death was noninferior to that with hearts donated after brain death. https://t.co/IymsknTqSE#cardiology pic.twitter.com/oYAS10fVJt
— NEJM (@NEJM) June 7, 2023
M-A | Accuracy of diagnostic tests in cardiac injury after blunt chest trauma
6 Jun, 2023 | 14:15h | UTC
Quality-improvement intervention | Impact of stopping preoperative screening for asymptomatic bacteriuria
2 Jun, 2023 | 12:29h | UTCCommentary: Hospital intervention reduces unnecessary screening, antibiotics for bacteriuria – CIDRAP
RCT | High-dose statin loading prior to CABG shows no benefit in major cardiac and cerebrovascular events
11 May, 2023 | 12:10h | UTCStatin loading before coronary artery bypass grafting: a randomized trial – European Heart Journal (link to abstract – $ for full-text)
Commentary: Statin Loading No Help Before Bypass Surgery: StaRT-CABG – TCTMD
Commentary on Twitter
Statin loading before coronary artery bypass grafting: a randomised trial https://t.co/br15X5lf7k @escardio #EHJ #ESCYoung @rladeiraslopes @ehj_ed pic.twitter.com/aQFlsJfaed
— European Society of Cardiology Journals (@ESC_Journals) May 8, 2023
M-A | Posterior pericardiotomy reduces the risk of atrial fibrillation after cardiac surgery
22 Mar, 2023 | 13:18h | UTCPosterior pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: a systematic review and meta-analysis of 25 randomised controlled trials – EuroIntervention (link to abstract – $ for full-text)
Related:
Consensus Paper | Pain management and opioid stewardship in adult cardiac surgery
8 Mar, 2023 | 14:22h | UTC
M-A | Effect of posterior pericardiotomy in cardiac surgery
28 Feb, 2023 | 13:34h | UTC
Guideline Synopsis | Management of thoracic aortic dissection
21 Feb, 2023 | 11:48h | UTCManagement of Thoracic Aortic Dissection – JAMA (free for a limited period)
Original Guidelines:
Review | Postoperative atrial fibrillation: from mechanisms to treatment
15 Feb, 2023 | 15:54h | UTCPostoperative atrial fibrillation: from mechanisms to treatment – European Journal of Cardiology
Commentary on Twitter
Postoperative atrial fibrillation: from mechanisms to treatment https://t.co/Alpb9eFRGb @escardio #EHJ #ESCYoung #cardiotwitter @ehj_ed @rladeiraslopes pic.twitter.com/s27PGkS49X
— European Society of Cardiology Journals (@ESC_Journals) February 14, 2023
Retrospective Study | Post-cardiac surgery fungal mediastinitis: clinical features, pathogens and outcome
15 Feb, 2023 | 15:40h | UTCPost-cardiac surgery fungal mediastinitis: clinical features, pathogens and outcome – Critical Care
RCT | Preliminary study on the effects of low-dose colchicine in patients undergoing non-CABG cardiac surgery
13 Feb, 2023 | 12:43h | UTC
Commentary on Twitter
✅Colchicine reduced cardiac injury after cardiac surgery
132 pts randomized to
?0.5 mg of colchicine or placebo in the perioperative periodColchicine compared with placebo
Cardiac makers⬇️
Atrial fibrillation⬇️ (few events, though)?https://t.co/c2mZmvj6kQ#CardioTwitter pic.twitter.com/N3DUjr1WsB
— Yuki Kotani, MD | 小谷 祐樹 (@YukiKotani5) February 8, 2023